GW1-2021-01601_Well Construction - GW1_20210404

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey to waTExzorTEs .
FROM TO DESCRIPTION
Well Contractor Name 10 % fL Q. /
3271-A fL fL
NC Well Contractor Certification Number
T5:07JTEW-CASINC„ o�;ion16 cased reBs QR'LiNER
B & K Well Drilling Inc FROM TO DIAMETER THICKNE S MATERIAL
0 ft. t fL 6 1/4 in SDR-21 PVC
Company Name
/,(� •:= 16.•IN�IER,C�iSING OR,7,�BING `etithermal¢lsedado ': ..
`3l � FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: __ _
List all applicable well cmrurucrioru permits(i.e t/:C i:uunn.Stale.Ver.mwe,eic.) It.
ft in.
ft ft. '. in-
3-Well Use(check well use):
13 SCREEN.
Water Supply Well: FROM TO DIAMETERI SLOT-1 E THICKNESS MATERIAL
❑Agricultural ;DMuni /Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) L n. in-
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL Bentonite JPour
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Rcmcdiation
19i-SA1!TD/GRAVEL PACK;i€a 'ra'`tilc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer Ztl: TNG:3aG atlaclddltloStaLshte
FROM TO DESCRIPTION(color,hardness,soil/rocke,grain size,etc.)
❑Gcothcnnal(1-icatinglCooling Return) ❑Other(explain under#21 Remarks) ft. ft
e Sa%
4.Date Well(s)Completed:,���_ Well ID# � ftTO fL 4144 7 J`O/�
5a./Well Location: ftft. ft
"aye
F;cility/6wncrNamc Facility ID#(if applicable) /� rj (,
Physical Address,City,and Zip
�del� llGu��y'•l�ss� i1TtEMARKS.:; K
�r----��r I _
County Parcel Identification No.(PIN) r
rncoci
g rjn)t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: o 1
(if well field,one lat/long is sufficient) 22.Certific on:
:
N w
6.Is(are)the well(s): ermanent or ❑Temporary Sign of a fed a ontractor Da
Br ignirrg Ihisjonn.1 herelm certify h the weW..$)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or � ISA AICAC 01C.0100 or ISA NCA 2C 10200 Well Construction Standards and mot a copy
If this is a repair,fill out known well consmuclon information and explain the nature of the of this record has been provided to the xr1!owner.
repair under,.21 remarkv.section or on the hack of this form 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page ito provide additional well construction info
construction,only I GW-I is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Q (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-T@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resource. (DWR),
10.Static water level below top of casing:40 (ft*) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lju,ater level is above casing,,use- ".
6.1/18 24b.For Injection Wells:Copy to DWR,Underground Tnjection Control(rUC)
11.Borehole diameter: (in-) Program,1636 MSC,Raleigh,NC 27699-1636 p
12.Well construction method:Air Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Cupy to the
(i.e.auger,rotary,cable,direct push-etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR.CCPCUA
Air Lift Permit Program,161!MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: hlor. Tabs Amount: 1 1I2 LbS
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 R
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